Biomimetic Scaffolds Based on Mn2+-, Mg2+-, and Sr2+-Substituted Calcium Phosphates Derived from Natural Sources and Polycaprolactone

The occurrence of bone disorders is steadily increasing worldwide. Bone tissue engineering (BTE) has emerged as a promising alternative to conventional treatments of bone defects, developing bone scaffolds capable of promoting bone regeneration. In this research, biomimetic scaffolds based on ion-substituted calcium phosphates, derived from cuttlefish bone, were prepared using a hydrothermal method. To synthesize Mn2+-substituted scaffolds, three different manganese concentrations (corresponding to 1, 2.5, and 5 mol% Mn substitutions for Ca into hydroxyapatite) were used. Also, syntheses with the simultaneous addition of an equimolar amount (1 mol%) of two (Mg2+ and Sr2+) or three ions (Mn2+, Mg2+, and Sr2+) were performed. A chemical, structural, and morphological characterization was carried out using X-ray diffraction, Fourier transform infrared spectroscopy, and scanning electron microscopy. The effects of the ion substitutions on the lattice parameters, crystallite sizes, and fractions of the detected phases were discussed. Multi-substituted (Mn2+, Mg2+, and Sr2+) scaffolds were coated with polycaprolactone (PCL) using simple vacuum impregnation. The differentiation of human mesenchymal stem cells (hMSCs), cultured on the PCL-coated scaffold, was evaluated using histology, immunohistochemistry, and reverse transcription-quantitative polymerase chain reaction analyses. The expression of collagen I, alkaline phosphatase, and dentin matrix protein 1 was detected. The influence of PCL coating on hMSCs behavior is discussed.

Influence of kinematic alignment on femorotibial kinematics in medial stabilized TKA design compared to mechanical alignment

INTRODUCTION

Worldwide more and more primary knee replacements are being performed. Kinematic alignment (KA) as one of many methods of surgical alignment has been shown to have a significant impact on kinematics and function. The aim of the present study was to compare KA and mechanical alignment (MA) with regard to femorotibial kinematics.

MATERIALS AND METHODS

Eight fresh frozen human specimens were tested on a knee rig during active knee flexion from 30 to 130°. Within the same specimen a medial stabilized (MS) implant design was used first with KA and then with MA.

RESULTS

The femorotibial kinematics showed more internal rotation of the tibia in KA compared to MA. At the same time, there was a larger medial rotation point in KA. Both alignment methods showed femoral rollback over the knee bend.

CONCLUSION

Relating to an increased internal rotation and a more precise medial pivot point, it can be concluded that KA combined with a MS implant design may partially support the reproduction of physiological knee joint mechanics.

Medical-Grade Poly(Lactic Acid)/Hydroxyapatite Composite Films: Thermal and In Vitro Degradation Properties

Production of biocompatible composite scaffolds shifts towards additive manufacturing where thermoplastic biodegradable polymers such as poly(lactic acid) (PLA) are used as matrices. Differences between industrial- and medical-grade polymers are often overlooked although they may affect properties and degradation behaviour as significantly as the filler addition. In the present research, composite films based on medical-grade PLA and biogenic hydroxyapatite (HAp) with 0, 10, and 20 wt.% of HAp were prepared by solvent casting technique. The degradation of composites incubated in phosphate-buffered saline solution (PBS) at 37 °C after 10 weeks showed that the higher HAp content slowed down the hydrolytic PLA degradation and improved its thermal stability. Morphological nonuniformity after degradation was indicated by the different glass transition temperatures (T_g) throughout the film. The T_g of the inner part of the sample decreased significantly faster compared with the outer part. The decrease was observed prior to the weight loss of composite samples.

Effects of Different Surface Treatments of Woven Glass Fibers on Mechanical Properties of an Acrylic Denture Base Material

Silanized glass fibers are popular reinforcements of acrylic denture base materials. To increase the number of surface hydroxyl groups and to improve interfacial adhesion between the matrix and reinforcements, acid or base treatments of glass fibers are commonly performed before the silanization. However, limited data are available on the effect of these treatments on the mechanical properties of acrylic matrix composite materials used for denture base applications. In this work, before the silanization of a woven glass fiber fabric (GF) with 3-(trimethoxysilyl) propyl methacrylate, activation pretreatments using HCl and NH₄OH aqueous solutions have been performed. To characterize the glass surface, FTIR spectroscopy was used. Specimens of cured acrylic denture base resin and composites were divided into five groups: (1) cured acrylic denture base resin-control group; (2) composite with non-silanized GF; (3) composite with silanized GF; (4) composite with NH₄OH activated and silanized GF; (5) composite with HCl activated and silanized GF. The flexural and impact properties of specimens were evaluated by means of three-point-bending tests and Charpy impact testing, respectively. The residual reactivity of the samples was analyzed using differential scanning calorimetry. The results of mechanical testing showed that acid and base pretreatments of the glass fabric had a positive effect on the flexural modulus of prepared composites but a negative effect on their impact strength. Possible interfacial adhesion mechanisms and the diffusion control of isothermal cure reactions due to vitrification have been discussed.

A multicentre, randomised, double-blind, phase II study to evaluate the tolerability of an induction dose escalation of everolimus in patients with metastatic breast cancer (DESIREE)

BACKGROUND

Stomatitis is one of the main reasons to discontinue everolimus in patients with hormone receptor-positive (HR+)/human epidermal growth factor receptor 2-negative (HER2-) metastatic breast cancer (mBC). To decrease stomatitis and subsequently early treatment discontinuations or dose reductions, the DESIREE trial investigated the use of a stepwise dose-escalation schedule of everolimus (EVE esc).

PATIENTS AND METHODS

DESIREE is a phase II, multicentre, randomised, double-blind, placebo-controlled trial in patients with HR+/HER2- mBC and progression/relapse after nonsteroidal aromatase inhibitor treatment. Patients were randomised to EVE esc (2.5 mg/day, week 1; 5 mg/day, week 2; 7.5 mg/day, week 3; 10 mg/day, weeks 4-24) or everolimus 10 mg/day (EVE 10mg) for 24 weeks plus exemestane. The primary endpoint was the incidence of stomatitis episodes grade ≥2 within 12 weeks of treatment. The secondary endpoints included toxicity, relative total dose intensity (RTDI) and quality of life (QoL).

RESULTS

A total of 160 patients were randomised and 156 started treatment (EVE esc: 80; EVE 10mg: 76). The median age of patients was 64 years (range 33-85), 56.3% patients in the EVE esc arm versus 42.1% in the EVE 10mg arm had liver metastasis (P = 0.081) and 62.5% versus 51.3% received over one metastatic therapy line (P = 0.196). Within 12 weeks, the incidence of stomatitis episodes grade ≥2 was significantly lower in the EVE esc arm compared with the EVE 10mg arm (28.8% versus 46.1%; odds ratio 0.47, 95% confidence interval 0.24-0.92; P = 0.026). Toxicity was in line with the known safety profile without new safety concerns. The median RTDI was 91.1% in the EVE esc arm versus 80.0% in the EVE 10mg arm (P = 0.329). Discontinuation rate in the first 3 weeks was 6.3% versus 15.8%, respectively (P = 0.073). QoL was comparable between the two treatment arms.

CONCLUSIONS

A dose-escalation schema of everolimus over 3 weeks can be successfully used to reduce the incidence of high-grade stomatitis in the first 12 weeks of treatment in patients with HR+/HER2- mBC.

TRIAL REGISTRATION

ClinicalTrials.govNCT02387099; https://clinicaltrials.gov/ct2/show/NCT02387099.

POS0941 LONG-TERM CLINICAL OUTCOMES OF CERTOLIZUMAB PEGOL TREATMENT IN PATIENTS WITH ACTIVE NON‑RADIOGRAPHIC AXIAL SPONDYLOARTHRITIS STRATIFIED BY BASELINE MRI AND C-REACTIVE PROTEIN STATUS

Background

Certolizumab pegol (CZP) has demonstrated clinical efficacy in patients with active non-radiographic axial spondyloarthritis (nr-axSpA) and objective signs of inflammation during the 52-week (wk) placebo (PBO)-controlled period and 104 wk open-label (OL) safety follow-up extension (SFE) of the C-axSpAnd study.1 There is, however, a paucity of data on the long-term efficacy of biologics in nr-axSpA according to patients’ baseline MRI and C-reactive protein (CRP) status.

Objectives

This post hoc analysis from C-axSpAnd aimed to evaluate whether patients’ baseline MRI and CRP status impacted long-term (3-year) clinical responses to CZP.

Methods

C-axSpAnd (NCT02552212) was a 3-year, phase 3, multicentre study. Adults (N=317) with nr-axSpA fulfilling the Assessment of SpondyloArthritis international Society (ASAS) classification criteria and objective signs of inflammation (CRP ≥ upper limit of normal (10 mg/L) [CRP+] and/or evidence of sacroiliitis on MRI [MRI+])2 were randomised 1:1 to PBO or CZP (400 mg at Wks 0, 2 and 4, then 200 mg every 2 wks [Q2W]) for 52 wks.3 Those enrolled into the SFE received OL CZP (200 mg Q2W) for an additional 104 wks.

Ankylosing Spondylitis Disease Activity Score (ASDAS) and Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) alongside the percentage of patients achieving ASDAS major improvement (ASDAS-MI, C-axSpAnd primary outcome) and ASAS 40% response (ASAS40) at Wks 52 and 156 were assessed according to prespecified subgroups based on MRI/CRP status (MRI+/CRP+, MRI−/CRP+, MRI+/CRP−). All data are reported as observed case.

Results

243/317 (76.7%) patients entered the SFE, 120 from the group initially randomised to CZP (36 MRI+/CRP+, 32 MRI−/CRP+ and 52 MRI+/CRP−) and 123 from the initial PBO group (30 MRI+/CRP+, 34 MRI−/CRP+ and 59 MRI+/CRP−; 75/123 had switched to OL treatment in the 52 wk double-blind phase). 206/243 completed the SFE; 102/120 (85.0%) from the group initially randomised to CZP, 104/123 (84.6%) from the initial PBO group.

Among CZP-randomised patients, mean ASDAS was similar between timepoints (MRI+/CRP+: 1.6 at Wk 52 vs 1.6 at Wk 156; MRI−/CRP+: 2.1 vs 2.2; MRI+/CRP−: 1.7 vs 1.6), the percentage achieving ASDAS-MI was lower at Wk 156 compared to Wk 52 across all subgroups (Figure 1 A). Patients initially randomised to PBO showed improvements in mean ASDAS over time (MRI+/CRP+: 2.1 Wk 52 vs 1.8 Wk 156; MRI−/CRP+: 2.2 vs 1.9; MRI+/CRP−: 2.0 vs 1.7) and a sustained proportion of patients achieved ASDAS-MI.

Similar results were shown for BASDAI, with mean scores for CZP-randomised patients sustained from Wk 52 to Wk 156 across all subgroups (Figure 1 B). Mean BASDAI decreased (indicative of clinical improvements) from Wk 52 to Wk 156 in patients initially randomised to PBO, at which point the values aligned with those reported for the CZP-randomised group.

In CZP-randomised patients, ASAS40 responses were sustained at Wk 156 compared to Wk 52. An increased percentage of patients achieved ASAS40 in all MRI/CRP subgroups initially randomised to PBO at Wk 156 compared to Wk 52 (Figure 1 C).

Conclusion

In this analysis of patients with nr-axSpA and objective signs of inflammation, long-term clinical outcomes achieved after 1 year were generally sustained at 3 years across MRI+/CRP+, MRI−/CRP+ and MRI+/CRP− subgroups; ASDAS-MI was numerically highest in the MRI+/CRP+ subgroup.

References

[1]van der Heijde D. Arthritis Rheumatol 2021;73 (suppl 10);

[2]Lambert RG. Ann Rheum Dis 2016;75(11):1958–63;

[3]Deodhar A. Arthritis Rheumatol 2019;71(7):1101–11.

Acknowledgements

This study was funded by UCB Pharma. Editorial services were provided by Costello Medical and funded by UCB Pharma.

Disclosure of Interests

Philip Robinson Consultant of: Personal fees from AbbVie, Atom Biosciences, Eli Lilly, Gilead, Janssen, Novartis, Roche, Pfizer and UCB Pharma, Grant/research support from: Grant funding from Janssen, Novartis and UCB Pharma; meeting attendance support from Bristol Myers Squibb, Lilly, Pfizer and Roche, Walter P Maksymowych Consultant of: Honoraria/consulting fees from AbbVie, Boehringer Ingelheim, Celgene, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer and UCB Pharma, Grant/research support from: Research grants from AbbVie and Pfizer; educational grants from AbbVie, Janssen, Novartis and Pfizer; Chief Medical Officer for CARE Arthritis Limited., Lianne S. Gensler Speakers bureau: Speaker for AbbVie, Eli Lilly, Novartis and UCB Pharma, Consultant of: Consulting fees from AbbVie, Celgene, Eli Lilly, Janssen, Novartis and UCB Pharma, Martin Rudwaleit Speakers bureau: Speaker for AbbVie, Eli Lilly, Novartis and UCB Pharma, Consultant of: Consulting fees from AbbVie, Celgene, Eli Lilly, Janssen, Novartis and UCB Pharma, Bengt Hoepken Shareholder of: Stockholder of UCB Pharma, Employee of: Employee of UCB Pharma, Lars Bauer Shareholder of: Stockholder of UCB Pharma, Employee of: Employee of UCB Pharma, Thomas Kumke Shareholder of: Stockholder of UCB Pharma, Employee of: Employee of UCB Pharma, Mindy Kim Shareholder of: Stockholder of UCB Pharma, Employee of: Employee of UCB Pharma, Atul Deodhar Speakers bureau: Speaker for Janssen, Novartis and Pfizer, Consultant of: Consulting fees from AbbVie, Amgen, Aurinia, Bristol Myers Squibb, Celgene, Eli Lilly, GSK, Janssen, MoonLake, Novartis, Pfizer and UCB Pharma, Grant/research support from: Research grants from AbbVie, Eli Lilly, GSK, Novartis, Pfizer and UCB Pharma

Feeding guanidinoacetic acid to broiler chickens can compensate for low dietary metabolisable energy formulation

1. This study compared the responses of broilers to diets supplemented with the same level of guanidinoacetic acid (GAA) but formulated to have different N-corrected apparent metabolisable energy (AMEn) contents. The study involved 1280, one-day-old Ross 308 broilers, in 64 pens comprising 32 pens of males and 32 pens females, (20 birds in each) aged from 0 to 42 days.2. Commercial AME levels of 12.55 MJ/kg, 12.97 MJ/kg and 13.18 MJ/kg in the starter, grower and finisher diets, respectively, were set for the positive control (PC) feed. Four dietary treatments were prepared: PC (as above); negative control 1 (NC; PC - 0.21 MJ ME /kg); NC1+ 0.06% GAA; NC2 (PC - 0.42 MJ ME/kg + 0.06% GAA). Each diet was provided in 16 pens (eight male and eight female), following randomisation.3. Overall, birds fed NC1 had lower feed intakes (FI) compared to birds fed the PC and NC2+GAA, lower weight gain (WG) compared to all the other diets and lower final body weight than birds fed the GAA diets (P<0.05). There was a diet x sex interaction (P=0.039), whereby feeding NC+GAA to female birds improved feed efficiency compared to being fed NC2 and NC1+GAA, but not in males. Birds fed diets with GAA had a higher poultry efficiency factor (P < 0.001) than those fed NC1.4. There were no effects of treatment or sex on litter moisture, footpad score, white striping, wooden breast, AMEn, dry matter and fat retention (P>0.05). However, the diet NC1+GAA had 11.2% higher nitrogen retention coefficient compared to the NC1 diet (P=0.038).6. Overall, the results implied that lower performance induced by a reduction of dietary AMEn in the range of 0.21 to 0.42 MJ/kg was more than compensated by supplementing 600 g/t GAA to the feed.

POS0896 PREDICTORS OF RESPONSE IN PATIENTS WITH NON-RADIOGRAPHIC AXIAL SPONDYLOARTHRITIS RECEIVING CERTOLIZUMAB PEGOL IN THE C-AXSPAND STUDY

Background:

Identification of predictive clinical factors of long-term treatment response in non-radiographic axial spondyloarthritis (nr-axSpA) may contribute to improved management of patients with this chronic disease. Certolizumab pegol (CZP) is currently the only FDA-approved tumour necrosis factor inhibitor (TNFi) for treatment of nr-axSpA.1

Objectives:

To identify whether any demographic or baseline characteristics of nr-axSpA patients from the C-axSpAnd study2 are predictive of achieving a clinical response after 1 year of CZP treatment.

Methods:

C-axSpAnd (NCT02552212) was a phase 3, interventional multicentre study including a 52-week double-blind, placebo-controlled period. Full study design is reported elsewhere.2 Multivariate stepwise logistic regression analysis was used to identify predictors of response for the primary efficacy variable (Ankylosing Spondylitis Disease Activity Score – major improvement [ASDAS-MI] at Week 52) and the main secondary efficacy variable (Assessment of SpondyloArthritis international Society 40% [ASAS40] at Week 52) in patients randomised to CZP 200 mg every 2 weeks (Q2W). Predictive factors used in the model included demographic and baseline characteristics, and clinical outcomes at Week 12. A p value ≤0.05 was required for forward selection into the model and p=0.1 for backward elimination from the model. Non-responder imputation was used to account for missing data or values collected after switching to open-label treatment. A sensitivity analysis was conducted to account for patients who had changes in their non-biologic background medication during the 52-week placebo-controlled period.

Results:

A total of 159/317 patients were randomised to CZP 200 mg Q2W and 158/317 to placebo. Predictive factors identified for Week 52 ASDAS-MI in the CZP-treated patients included being positive for both presence of sacroiliitis on MRI (MRI+) and human leukocyte antigen (HLA)-B27 (HLA-B27+), having a higher Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) at baseline, and having a larger Week 12 improvement in ASDAS (Figure 1A). For ASAS40 response, MRI+/HLA-B27+ was also identified as a predictor of Week 52 response, along with a lower baseline Bath AS Metrology Index (BASMI) and larger Week 12 improvements in Patient Global Assessment of Disease Activity (PtGADA) and AS Quality of Life (ASQoL; Figure 1B). Sensitivity analysis identified the same predictors for ASDAS-MI and ASAS40, with the exception of change from baseline in PtGADA as a predictor of ASAS40. Sensitivity analysis also identified achievement of Week 12 ASAS40 as a predictor of Week 52 ASAS40. In placebo-treated patients, no meaningful predictors of response at Week 52 were identified.

Conclusion:

Presence of sacroiliitis on MRI and HLA-B27 positivity were identified as consistent predictors of Week 52 response (ASDAS-MI and ASAS40) in nr-axSpA patients treated with CZP. To our knowledge, this is the first report from an interventional 52-week placebo-controlled study in nr-axSpA to identify objective clinical features, particularly the presence of sacroiliac joint inflammation, as being predictive of response.

References:

[1]Ashrafi M. Curr Opin Rheumatol 2020;32:321–9.

[2]Deodhar A. Arthritis Rheumatol 2019;71:1101–11.

Acknowledgements:

This study was funded by UCB Pharma. Editorial services were provided by Costello Medical.

Disclosure of Interests:

Walter P Maksymowych Speakers bureau: AbbVie, Janssen, Novartis, Pfizer, UCB Pharma, Consultant of: AbbVie, BMS, Boehringer, Eli Lilly, Novartis, Pfizer, UCB Pharma, Grant/research support from: AbbVie, Novartis, Pfizer, Thomas Kumke Shareholder of: UCB Pharma, Employee of: UCB Pharma, Simone Auteri Shareholder of: UCB Pharma, Employee of: UCB Pharma, Bengt Hoepken Shareholder of: UCB Pharma, Employee of: UCB Pharma, Lars Bauer Shareholder of: UCB Pharma, Employee of: UCB Pharma, Martin Rudwaleit Speakers bureau: AbbVie, Eli Lilly, Novartis, UCB Pharma, Consultant of: AbbVie, Celgene, Eli Lilly, Janssen, Novartis, UCB Pharma

POS0229 DISEASE ACTIVITY AND INFLAMMATION FOLLOWING WITHDRAWAL OF CERTOLIZUMAB PEGOL TREATMENT IN AXIAL SPONDYLOARTHRITIS PATIENTS WHO DID NOT EXPERIENCE FLARES DURING THE C-OPTIMISE STUDY

Background:

C-OPTIMISE was a phase 3b clinical trial investigating certolizumab pegol (CZP) maintenance dose continuation, reduction or withdrawal following achievement of sustained remission in patients with axial spondyloarthritis (axSpA). During the C-OPTIMISE maintenance period, the majority of patients randomised to CZP, either the full or reduced maintenance dose, did not experience disease flares. Conversely, in those who had CZP withdrawn, only a minority of patients remained flare-free.1

Objectives:

This post-hoc analysis evaluates disease activity and clinical markers of inflammation in patients who did not experience a disease flare following randomisation to CZP full maintenance dose, CZP reduced maintenance dose or placebo (PBO) during the maintenance period (Weeks 48–96) of C-OPTIMISE.

Methods:

C-OPTIMISE (NCT02505542) was a multicentre, double-blind, parallel-group, randomised phase 3b study with a 48-week open-label run-in period.1 Adult patients with early (<5 years’ symptom duration) active axSpA received open-label CZP 200 mg every 2 weeks (Q2W) for the first 48 weeks; from Week 48, patients who achieved sustained remission (Ankylosing Spondylitis Disease Activity Score [ASDAS] <1.3 at Week 32 or 36 and Week 48) were randomised 1:1:1 to double-blind CZP 200 mg Q2W (full maintenance dose), CZP 200 mg Q4W (reduced maintenance dose) or PBO for a further 48 weeks (maintenance period). A flare was defined as ASDAS ≥2.1 at two consecutive visits or ASDAS >3.5 at any visit. We report ASDAS, Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), and C-reactive protein (CRP) and fecal calprotectin levels during Weeks 48–96 in CZP- and PBO-randomised patients who did not experience a flare (i.e. completed Week 96 on randomised treatment). Missing data were imputed using last observation carried forward.

Results:

Of 313 patients entering the maintenance period at Week 48, 197 (62.9%) completed Week 96 on randomised treatment without experiencing a flare; of these, 89 (85.6%) and 84 (80.0%) patients were in the CZP 200 mg Q2W and CZP 200 mg Q4W arm, respectively, with only 24 (23.1%) patients randomised to PBO not experiencing a flare. Baseline characteristics of these patients are shown in the Table 1. During Weeks 48–96, disease activity (ASDAS, BASDAI) and CRP levels were comparable between the CZP full and reduced maintenance dose group, and lower in both CZP arms than in PBO (Figure 1 A–C). From Week 60 up to Week 96, PBO patients who did not flare had consistently higher mean ASDAS, BASDAI and CRP levels compared with CZP-randomised patients (Figure 1 A–C). Similarly, there was a greater increase in fecal calprotectin levels between Weeks 48 and 96 in the PBO arm compared with both CZP arms (Figure 1 D).

Table 1.

Baseline (Week 0) characteristics of patients who did not experience flares during the C-OPTIMISE maintenance period

Placebo (n=24)CZP 200 mg Q4W (n=84)CZP 200 mg Q2W (n=89)Age (years), mean (SD)29.8 (7.4)32.9 (6.7)32.4 (7.2)Male, n (%)19 (79.2)69 (82.1)69 (77.5)Time since diagnosis (years)Mean (SD)2.0 (1.8)2.0 (1.7)2.5 (1.6)Median1.21.22.7Symptom duration (years)Mean (SD)2.7 (1.7)3.4 (1.9)3.9 (2.9)Median2.83.53.9ASDAS, mean (SD)3.4 (0.8)3.7 (0.8)3.7 (0.7)BASDAI, mean (SD)6.3 (1.1)6.6 (1.5)6.4 (1.4)CRP (mg/L), geometric mean6.287.887.35Fecal calprotectin (µg/g), mean (SD)71.8 (111.4)87.1 (110.5)81.0 (120.0)

SD: standard deviation.

Conclusion:

Despite not meeting the threshold for a flare, consistently higher disease activity and increases in serologic and inflammatory biomarkers were observed in PBO-randomised patients who did not experience a flare during the C-OPTIMISE study compared to those who remained on CZP. These findings confirm that patients with axSpA who achieve sustained remission benefit from continued CZP treatment, either with the full or reduced maintenance dose, over treatment withdrawal.

References:

[1]Landewé R. Ann Rheum Dis 2020;79:920–8.

Acknowledgements:

This study was funded by UCB Pharma. Editorial services were provided by Costello Medical.

Disclosure of Interests:

Lianne S. Gensler Consultant of: AbbVie, Eli Lilly, Gilead, GSK, Novartis, Pfizer, UCB Pharma, Grant/research support from: Pfizer, Xenofon Baraliakos Speakers bureau: AbbVie, BMS, Chugai, Eli Lilly, Galapagos, Gilead, Novartis, Merck, Pfizer, UCB Pharma, Paid instructor for: AbbVie, BMS, Chugai, Eli Lilly, Galapagos, Gilead, Novartis, Merck, Pfizer, UCB Pharma, Consultant of: AbbVie, BMS, Chugai, Eli Lilly, Galapagos, Gilead, Novartis, Merck, Pfizer, UCB Pharma, Grant/research support from: AbbVie, Merck, Novartis, Lars Bauer Shareholder of: UCB Pharma, Employee of: UCB Pharma, Bengt Hoepken Shareholder of: UCB Pharma, Employee of: UCB Pharma, Thomas Kumke Shareholder of: UCB Pharma, Employee of: UCB Pharma, Mindy Kim Shareholder of: UCB Pharma, Employee of: UCB Pharma, Robert B.M. Landewé Speakers bureau: Abbott, Amgen, BMS, Centocor, Merck, Pfizer, Roche, Schering-Plough, UCB Pharma, Wyeth, Consultant of: Abbott, Ablynx, Amgen, AstraZeneca, BMS, Centocor, GSK, Merck, Novartis, Pfizer, Roche, Schering-Plough, UCB Pharma, Wyeth, Grant/research support from: Abbott, Amgen, Centocor, Novartis, Pfizer, Roche, Schering-Plough, UCB Pharma, Wyeth

OP0103 DOES GENDER, AGE OR SUBPOPULATION INFLUENCE THE MAINTENANCE OF CLINICAL REMISSION IN AXIAL SPONDYLOARTHRITIS FOLLOWING CERTOLIZUMAB PEGOL DOSE REDUCTION?

Background:

Previous studies have shown that withdrawing tumour necrosis factor inhibitors (TNFi) in patients (pts) with axial spondyloarthritis (axSpA) who have achieved sustained remission often leads to relapse.1However, none have formally tested TNFi dose reduction strategies in a broad axSpA population or evaluated whether relapse following TNFi dose reduction and withdrawal is associated with a specific demographic subgroup.

Objectives:

C-OPTIMISE evaluated the percentage of pts without flare after TNFi dose continuation, reduction or withdrawal in adults with early axSpA treated with the Fc-free, PEGylated TNFi certolizumab pegol (CZP). Here, we analyse whether responses to reduced maintenance dose were comparable in pts stratified by axSpA subpopulation, gender and age.

Methods:

C-OPTIMISE (NCT02505542) was a multicentre, two-part phase 3b study in adults with early (<5 years’ symptom duration) active axSpA (stratified for radiographic [r]- and non-radiographic [nr]- axSpA). Pts received CZP 200 mg every 2 weeks (wks) (Q2W; 400 mg loading dose at Wks 0, 2 and 4) during the open-label induction period. At Wk 48, pts in sustained remission (Ankylosing Spondylitis Disease Activity Score [ASDAS] <1.3 at Wk 32 or 36 [if ASDAS <1.3 at Wk 32, it must be <2.1 at Wk 36, or vice versa] and at Wk 48) were randomised to double-blind full maintenance dose (CZP 200 mg Q2W); reduced maintenance dose (CZP 200 mg every 4 wks [Q4W]) or placebo (PBO) for a further 48 wks (maintenance period). The primary endpoint was the percentage of pts not experiencing a flare (ASDAS ≥2.1 at two consecutive visits or ASDAS >3.5 at any timepoint) during Wks 48–96. Analyses were conducted on subgroups according to axSpA subpopulation, gender and age ≤/> the median age of the randomised set (32 years).

Results:

During the 48-wk induction period, 43.9% of patients (323/736) achieved sustained remission and 313 pts entered the 48-wk maintenance period (r/nr-axSpA: 168/145 pts; males/females: 247/66 pts; age ≤32/>32: 165/148 pts). During the maintenance period, responses in r- and nr-axSpA pts were comparable across all three randomised arms. 83.9% r-axSpA and 83.3% nr-axSpA pts receiving the full CZP maintenance dose did not experience a flare, and in the reduced maintenance dose arm 82.1% r-axSpA and 75.5% nr-axSpA pts did not experience a flare. In the PBO group this was reduced to 17.9% and 22.9%, respectively. Similar responses were seen in pts stratified by gender or age, with substantially higher percentages of pts randomised to CZP full or reduced maintenance dose remaining free of flares compared to PBO in all subgroups (Figure).

Conclusion:

The results of C-OPTIMISE indicate that a reduced maintenance dose is suitable for pts with axSpA who achieve sustained remission following 1 year of CZP treatment, regardless of axSpA subpopulation, gender or age. Complete treatment withdrawal is not recommended due to the high risk of flare.

References:

[1]Landewe R. Lancet 2018;392:134–44.

Acknowledgments:

This study was funded by UCB Pharma. Editorial services were provided by Costello Medical

Disclosure of Interests:

Robert B.M. Landewé Consultant of: AbbVie; AstraZeneca; Bristol-Myers Squibb; Eli Lilly & Co.; Galapagos NV; Novartis; Pfizer; UCB Pharma, Désirée van der Heijde Consultant of: AbbVie, Amgen, Astellas, AstraZeneca, BMS, Boehringer Ingelheim, Celgene, Cyxone, Daiichi, Eisai, Eli-Lilly, Galapagos, Gilead Sciences, Inc., Glaxo-Smith-Kline, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sanofi, Takeda, UCB Pharma; Director of Imaging Rheumatology BV, Maxime Dougados Grant/research support from: AbbVie, Eli Lilly, Merck, Novartis, Pfizer and UCB Pharma, Consultant of: AbbVie, Eli Lilly, Merck, Novartis, Pfizer and UCB Pharma, Speakers bureau: AbbVie, Eli Lilly, Merck, Novartis, Pfizer and UCB Pharma, Xenofon Baraliakos Grant/research support from: Grant/research support from: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Consultant of: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Speakers bureau: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Filip van den Bosch Consultant of: AbbVie, Celgene Corporation, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer, and UCB, Speakers bureau: AbbVie, Celgene Corporation, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer, and UCB, Karl Gaffney Grant/research support from: AbbVie, Celgene, MSD, Novartis, Pfizer, and UCB Pharma, Consultant of: AbbVie, Celgene, MSD, Novartis, Pfizer, and UCB Pharma, Speakers bureau: AbbVie, Celgene, MSD, Novartis, Pfizer, and UCB Pharma, Lars Bauer Employee of: UCB Pharma, Bengt Hoepken Employee of: UCB Pharma, Natasha de Peyrecave Employee of: UCB Pharma, Karen Thomas Employee of: UCB Pharma, Lianne S. Gensler Grant/research support from: Pfizer, Novartis, UCB, Consultant of: AbbVie, Eli Lilly, GSK, Novartis, UCB

THU0379 REDUCTION OF ANTERIOR UVEITIS FLARES IN PATIENTS WITH AXIAL SPONDYLOARTHRITIS FOLLOWING ONE YEAR OF TREATMENT WITH CERTOLIZUMAB PEGOL: 48-WEEK INTERIM RESULTS FROM A 96-WEEK OPEN-LABEL STUDY

Background:

Acute anterior uveitis (AAU), inflammation of the anterior uveal tract, is reported in up to 40% of patients (pts) with axial spondyloarthritis (axSpA).1AAU is associated with significant clinical burden; symptoms include blurred vision, photophobia and pain.2Previous studies have shown that TNF inhibitors (TNFi) can reduce AAU flare incidence in pts with radiographic axSpA,3-5but few have focused on pts across the full axSpA spectrum.

Objectives:

To analyse the impact of certolizumab pegol (CZP) treatment on AAU in pts with active radiographic and non-radiographic axSpA and a recent history of AAU.

Methods:

C-VIEW (NCT03020992) is an ongoing multicentre, open-label, phase 4 study. Pts had active axSpA according to the ASAS classification, a history of recurrent AAU (≥2 AAU flares in total and ≥1 AAU flare in the year prior to study entry), were HLA-B27 positive, and were eligible for TNFi treatment (previous failure of ≥2 NSAIDs, biologic naïve or had failed ≤1 TNFi). Pts received CZP 400 mg at Weeks (Wks) 0/2/4, then 200 mg every two wks (Q2W) to Wk 96. The primary variable was incidence of AAU flares compared to historic rates. A pre-specified interim analysis compared AAU incidence in the 48 wks prior to CZP treatment with the 48 wks of treatment, using Poisson regression adjusted for possible within-pt correlations, with period (pre- and post-baseline) and axSpA disease duration as covariates. Incidence rates (IR) were calculated based on the number of cases/pts at risk over 48 wks. Observed data are reported.

Results:

Of 115 enrolled pts, 89 initiated CZP treatment; 85 completed Wk 48. Baseline characteristics are shown in the Table. The 48-wk interim analysis revealed significantly fewer AAU flares/pt during CZP treatment vs before treatment (Figure; Poisson-adjusted IR: 0.2 vs 1.5, p<0.001). The number of pts experiencing 1 and ≥2 AAU flares (64.0% and 31.5% respectively) substantially reduced during CZP treatment (12.4% and 2.2%). After 48 wks CZP treatment, disease activity improved substantially (mean ± SD Ankylosing Spondylitis Disease Activity Score [ASDAS]: 2.0 ± 0.9; Bath Ankylosing Spondylitis Disease Activity Index [BASDAI]: 3.3 ± 2.1), with 31.4% pts achieving ASAS partial remission and 29.1% ASDAS major improvement. No new safety signals were identified.

Table.

Baseline characteristics

CZP 200 mg Q2W (N=89)Age (years), mean ± SD46.5 ± 11.2Male, n (%)56 (62.9)Racial group, n (%) Caucasian87 (97.8) Other2 (2.2)Diagnosis, n (%) Radiographic axSpA76 (85.4) Non-radiographic axSpA13 (14.6)Duration of axSpA (years), mean ± SD8.6 ± 8.4Time since onset of first uveitis flare (years), mean ± SD9.9 ± 9.0ASDAS, mean ± SD3.5 ± 0.9BASDAI, mean ± SD6.5 ± 1.5

Conclusion:

In this open-label study, AAU flare rate significantly reduced in axSpA pts with a history of recurrent AAU during the first 48 wks of CZP. Pts also experienced substantial improvements in axSpA disease activity.

References:

[1]Martin TM. Curr Opin Rheumatol 2002;14:337–41

[2]Bacchiega ABS. Rheumatology (Oxford) 2017;56:2060–7

[3]van der Heijde D. Rheumatology (Oxford) 2017;56:1498–509

[4]van Bentum RE. J Rheumatol 2019;46:153–9

[5]van Denderen JC. J Rheumatol 2014;41:1843–8

Acknowledgments:

This study was funded by UCB Pharma. Editorial services were provided by Costello Medical.

Disclosure of Interests:

Irene van der Horst-Bruinsma Grant/research support from: AbbVie, Novartis, Eli Lilly, Bristol-Myers Squibb, MSD, Pfizer, UCB Pharma, Consultant of: AbbVie, Novartis, Eli Lilly, Bristol-Myers Squibb, MSD, Pfizer, UCB Pharma, Rianne van Bentum: None declared, Frank Verbraak Grant/research support from: Bayer, Novartis, IDxDR, UCB Pharma, Consultant of: Bayer, Novartis, IDxDR, UCB Pharma, Thomas Rath Grant/research support from: AbbVie, Bristol-Myers Squibb, Chugai, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB Pharma, James Rosenbaum Consultant of: AbbVie, Corvus, Eyevensys, Gilead, Novartis, Janssen, Roche, UCB Pharma; royalties from UpToDate, Maria Misterska-Skora: None declared, Bengt Hoepken Employee of: UCB Pharma, Oscar Irvin-Sellers Employee of: UCB Pharma, Brenda VanLunen Employee of: UCB Pharma, Lars Bauer Employee of: UCB Pharma, Martin Rudwaleit Consultant of: AbbVie, BMS, Celgene, Janssen, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB Pharma

A novel pretherapeutic gene expression-based risk score for treatment guidance in gastric cancer

Background

Perioperative chemotherapy is an established treatment of advanced gastric cancer patients. Treatment selection is based on clinical staging (cT). We aimed to establish and validate a prognostic score including clinical and molecular factors, to optimize treatment decisions for these patients.

Patients and methods

We analyzed 626 carcinomas of the stomach and of the gastro-esophageal junction from two academic centers including primarily resected and pre-/perioperatively treated patients. Patients were divided into a training (N = 269) and validation (N = 357) set. Expression of 11 target genes was measured by quantitative PCR in resected tumors. A risk score to predict overall survival (OS) was generated and validated. Intra-tumoral heterogeneity was assessed by analyzing 50 tumor areas from 10 patients.

Results

A risk score including the expression of CCL5, CTNNB1, EXOSC3 and LZTR1 and the clinical parameters cT, tumor localization and histopathologic type suggested two groups with a significant difference in OS [hazard ratio (HR) 0.30; 95% confidence interval (CI) 0.17-0.52]. The risk score was successfully validated in an independent cohort (HR 0.32; 95% CI 0.21-0.51; P < 0.001) as well as in subgroups of primarily resected (HR 0.30; 95% CI 0.17-0.54; P < 0.001) and pre-/perioperatively treated patients (HR 0.37; 95% CI 0.17-0.81; P = 0.009). A significant difference in OS of high- and low-risk patients was also found in primarily resected patients with intestinal (HR 0.45; 95% CI 0.23-0.90; P = 0.020) and nonintestinal-type carcinomas (HR 0.1; 95% CI 0.02-0.42; P < 0.001). Intra-tumor heterogeneity analysis indicated a classification reliability of 95% for a supposed analysis of three biopsies.

Conclusion

The identified risk score could substantially contribute to an improved management of gastric cancer patients in the context of perioperative chemotherapy.

Intra- and interobserver reliability of glenoid fracture classifications by Ideberg, Euler and AO

Background

Representing 3%–5% of shoulder girdle injuries scapula fractures are rare. Furthermore, approximately 1% of scapula fractures are intraarticularfractures of the glenoid fossa. Because of uncertain fracture morphology and limited experience, the treatment of glenoid fossa fractures is difficult. The glenoid fracture classification by Ideberg (1984) and Euler (1996) is still commonly used in literature. In 2013 a new glenoid fracture classification was introduced by the AO. The purpose of this study was to examine the new AO classification in clinical practice in comparison with the classifications by Ideberg and Euler.

Methods

In total CT images of 84 patients with glenoid fossa fractures from 2005 to 2018 were included. Parasagittal, paracoronary and axial reconstructions were examined according to the classifications of Ideberg, Euler and the AO by 3 investigators (orthopedic surgeon, radiologist, student of medicine) at three individual time settings. Inter- and intraobserver reliability of the three classification systems were ascertained by computing Inter- and Intraclass (ICCs) correlation coefficients using Spearman’s rank correlation coefficient, 95%-confidence intervals as well as F-tests for correlation coefficients.

Results

Inter- and intraobserver reliability for the AO classification showed a perspicuous coherence (R = 0.74 and R = 0.79). Low to moderate intraobserver reliability for Ideberg (R = 0.46) and Euler classification (R = 0.41) was found. Furthermore, data show a low Interobserver reliability for both Ideberg and Euler classification (R < 0.2). Both the Inter- and Intraclass reliability using AO is significantly higher than those using Ideberg and Euler (p < 0.05). Using the new AO classification, it was possible to find a proper class for every glenoid fossa fracture. On average, according to Euler classification 10 of 84 fractures were not classifiable whereas to Ideberg classification 21 of 84 fractures were not classifiable.

Conclusion

The new AO classification system introduced 2013 facilitates reliable grading of glenoid fossa fractures with high inter- and intraobserver reliability in 84 patients using CT images. It should possibly be applied in order to enable a valid, reliable and consistent academic description of glenoid fossa fractures. The established classifications by Euler and Ideberg are not capable of providing a similar reliability.

An endophenotype approach to the genetics of alcohol dependence: a genome wide association study of fast beta EEG in families of African ancestry

Fast beta (20-28 Hz) electroencephalogram (EEG) oscillatory activity may be a useful endophenotype for studying the genetics of disorders characterized by neural hyperexcitability, including substance use disorders (SUDs). However, the genetic underpinnings of fast beta EEG have not previously been studied in a population of African-American ancestry (AA). In a sample of 2382 AA individuals from 482 families drawn from the Collaborative Study on the Genetics of Alcoholism (COGA), we performed a genome-wide association study (GWAS) on resting-state fast beta EEG power. To further characterize our genetic findings, we examined the functional and clinical/behavioral significance of GWAS variants. Ten correlated single-nucleotide polymorphisms (SNPs) (r²>0.9) located in an intergenic region on chromosome 3q26 were associated with fast beta EEG power at P<5 × 10^-8. The most significantly associated SNP, rs11720469 (β: -0.124; P<4.5 × 10^-9), is also an expression quantitative trait locus for BCHE (butyrylcholinesterase), expressed in thalamus tissue. Four of the genome-wide SNPs were also associated with Diagnostic and Statistical Manual of Mental Disorders Alcohol Dependence in COGA AA families, and two (rs13093097, rs7428372) were replicated in an independent AA sample (Gelernter et al.). Analyses in the AA adolescent/young adult (offspring from COGA families) subsample indicated association of rs11720469 with heavy episodic drinking (frequency of consuming 5+ drinks within 24 h). Converging findings presented in this study provide support for the role of genetic variants within 3q26 in neural and behavioral disinhibition. These novel genetic findings highlight the importance of including AA populations in genetics research on SUDs and the utility of the endophenotype approach in enhancing our understanding of mechanisms underlying addiction susceptibility.

Impulse control disorder related behaviours during long-term rotigotine treatment: a post hoc analysis

Background and purpose

Dopamine agonists in Parkinson's disease (PD) are associated with impulse control disorders (ICDs) and other compulsive behaviours (together called ICD behaviours). The frequency of ICD behaviours reported as adverse events (AEs) in long‐term studies of rotigotine transdermal patch in PD was evaluated.

Methods

This was a post hoc analysis of six open‐label extension studies up to 6 years in duration. Analyses included patients treated with rotigotine for at least 6 months and administered the modified Minnesota Impulse Disorders Interview. ICD behaviours reported as AEs were identified and categorized.

Results

For 786 patients, the mean (±SD) exposure to rotigotine was 49.4 ± 17.6 months. 71 (9.0%) patients reported 106 ICD AEs cumulatively. Occurrence was similar across categories: 2.5% patients reported ‘compulsive sexual behaviour’, 2.3% ‘buying disorder’, 2.0% ‘compulsive gambling’, 1.7% ‘compulsive eating’ and 1.7% ‘punding behaviour’. Examining at 6‐month intervals, the incidence was relatively low during the first 30 months; it was higher over the next 30 months, peaking in the 54–60‐month period. No ICD AEs were serious, and 97% were mild or moderate in intensity. Study discontinuation occurred in seven (9.9%) patients with ICD AEs; these then resolved in five patients. Dose reduction occurred for 23 AEs, with the majority (73.9%) resolving.

Conclusions

In this analysis of >750 patients with PD treated with rotigotine, the frequency of ICD behaviour AEs was 9.0%, with a specific incidence timeline observed. Active surveillance as duration of treatment increases may help early identification and management; once ICD behaviours are present rotigotine dose reduction may be considered.

A qualitative analysis to optimize a telemonitoring intervention for heart failure patients from disparity communities

Background

The use of telemonitoring is a promising approach to optimizing outcomes in the treatment of heart failure (HF) for patients living in the community. HF telemonitoring interventions, however, have not been tested for use with individuals residing in disparity communities.

Methods

The current study describes the results of a community based participatory research approach to adapting a telemonitoring HF intervention so that it is acceptable and feasible for use with a lower-income, Black and Hispanic patient population. The study uses the ADAPT-ITT framework to engage key community stakeholders in the process of adapting the intervention in the context of two consecutive focus groups. In addition, data from a third focus group involving HF telemonitoring patient participants was also conducted. All three focus group discussions were audio recorded and professionally transcribed and lasted approximately two hours each. Structural coding was used to mark responses to topical questions in the interview guide.

Results

This is the first study to describe the formative process of a community-based participatory research study aimed at optimizing telehealth utilization among African-American and Latino patients from disparity communities. Two major themes emerged from qualitative analyses of the focus group data. The first theme that arose involved suggested changes to the equipment that would maximize usability. Subthemes identified included issues that reflect the patient populations targeted, such as Spanish translation, font size and medical jargon. The second theme that arose involved suggested changes to the RCT study structure in order to maximize participant engagement. Subthemes also identified issues that reflect concerns of the targeted patient populations, such as the provision of reassurances regarding identity protection to undocumented patients in implementing an intervention that utilizes a camera, and that their involvement in telehealth monitoring would not replace their clinic care, which for many disparity patients is their only connection to medical care.

Conclusions

The adaptation, based on the analysis of the data from the three focus groups, resulted in an intervention that is acceptable and feasible for HF patients residing in disparity communities.

Trial registration

NCT02196922; ClinicalTrials.gov (US National Institutes of Health).

Electronic supplementary material

The online version of this article (doi:10.1186/s12911-016-0300-9) contains supplementary material, which is available to authorized users.

Is there any advantage in placing an additional calcar screw in locked nailing of proximal humeral fractures?

BACKGROUND

The objective of this study was to evaluate the biomechanical effect of an additional unlocked calcar screw compared to a standard setting with three proximal humeral head screws alone for fixation of an unstable 2-part fracture of the surgical neck.

HYPOTHESIS

The additional calcar screw improves stiffness and failure load.

METHODS

Fourteen fresh frozen humeri were randomized into two equal sized groups. An unstable 2-part fracture of the surgical neck was simulated and all specimens were fixed with the MultiLoc(®)-nail. Group I represented a basic screw setup, with three locked head screws and two unlocked shaft screws. Group II was identical with a supplemental unlocked calcar screw (CS). Stiffness tests were performed in torsional loading, as well as in axial and in 20° abduction/20° adduction modes. Subsequently cyclic loading and load-to-failure tests were performed. Resulting stiffness, displacement under cyclic load and ultimate load were compared between groups using the t-test for independent variables (α=0.05).

RESULTS

No significant differences were observed between the groups in any of the biomechanical parameters. Backing out of the CS was observed in three cases.

DISCUSSION

The use of an additional unlocked calcar screw does not provide mechanical benefit in locked nailing of an unstable 2-part fracture of the surgical neck.

Survival after neoadjuvant chemotherapy with or without bevacizumab or everolimus for HER2-negative primary breast cancer (GBG 44-GeparQuinto)†

BACKGROUND

The GeparQuinto study showed that adding bevacizumab to 24 weeks of anthracycline-taxane-based neoadjuvant chemotherapy increases pathological complete response (pCR) rates overall and specifically in patients with triple-negative breast cancer (TNBC). No difference in pCR rate was observed for adding everolimus to paclitaxel in nonearly responding patients. Here, we present disease-free (DFS) and overall survival (OS) analyses.

PATIENTS AND METHODS

Patients (n = 1948) with HER2-negative tumors of a median tumor size of 4 cm were randomly assigned to neoadjuvant treatment with epirubicin/cyclophosphamide followed by docetaxel (EC-T) with or without eight infusions of bevacizumab every 3 weeks before surgery. Patients without clinical response to EC ± Bevacizumab were randomized to 12 weekly cycles paclitaxel with or without everolimus 5 mg/day. To detect a hazard ratio (HR) of 0.75 (α = 0.05, β = 0.8) 379 events had to be observed in the bevacizumab arms.

RESULTS

With a median follow-up of 3.8 years, 3-year DFS was 80.8% and 3-year OS was 89.7%. Outcome was not different for patients receiving bevacizumab (HR 1.03; P = 0.784 for DFS and HR 0.974; P = 0.842 for OS) compared with patients receiving chemotherapy alone. Patients with TNBC similarly showed no improvement in DFS (HR = 0.99; P = 0.941) and OS (HR = 1.02; P = 0.891) when treated with bevacizumab. No other predefined subgroup (HR+/HER2-; locally advanced (cT4 or cN3) or not; cT1-3 or cT4; pCR or not) showed a significant benefit. No difference in DFS (HR 0.997; P = 0.987) and OS (HR 1.11; P = 0.658) was observed for nonearly responding patients receiving paclitaxel with or without everolimus overall as well as in subgroups.

CONCLUSIONS

Long-term results, in opposite to the results of pCR, do not support the neoadjuvant use of bevacizumab in addition to an anthracycline-taxane-based chemotherapy or everolimus in addition to paclitaxel for nonearly responding patients.

CLINICAL TRIAL NUMBER

NCT 00567554, www.clinicaltrials.gov.

Mechanisms of antihyperglycaemic action of efaroxan in mice: time for reappraisal of α2A-adrenergic antagonism in the treatment of type 2 diabetes?

AIMS/HYPOTHESIS

Inspired by recent speculation about the potential utility of α(2A)-antagonism in the treatment of type 2 diabetes, the study examined the contribution of α(2)-antagonism vs other mechanisms to the antihyperglycaemic activity of the imidazoline (±)-efaroxan.

METHODS

Effects of the racemate and its pure enantiomers on isolated pancreatic islets and beta cells in vitro, as well as on hyperglycaemia in vivo, were investigated in a comparative manner in mice.

RESULTS

In isolated perifused islets, the two enantiomers of efaroxan were equally potent in counteracting inhibition of insulin release by the ATP-dependent K(+) (K(ATP)) channel-opener diazoxide but (+)-efaroxan, the presumptive carrier of α(2)-antagonistic activity, was by far superior in counteracting inhibition of insulin release by the α(2)-agonist UK14,304. In vivo, (+)-efaroxan improved oral glucose tolerance at 100-fold lower doses than (-)-efaroxan and, in parallel with observations made in vitro, was more effective in counteracting UK14,304-induced than diazoxide-induced hyperglycaemia. The antihyperglycaemic activity of much higher doses of (-)-efaroxan was associated with an opposing pattern (i.e. with stronger counteraction of diazoxide-induced than UK14,304-induced hyperglycaemia), which implicates a different mechanism of action.

CONCLUSIONS/INTERPRETATION

The antihyperglycaemic potency of (±)-efaroxan in mice is almost entirely due to α(2)-antagonism, but high doses can also lower blood glucose via another mechanism. Our findings call for reappraisal of the possible clinical utility of α(2A)-antagonistic compounds in recently identified subpopulations of patients in which a congenitally higher level of α(2A)-adrenergic activation contributes to the development and pathophysiology of type 2 diabetes.

[Traumatic optic nerve neuropathy. Longterm results following microsurgical optic nerve decompression]

BACKGROUND

Traumatic optic nerve neuropathy (TON) is defined as injury to the optic nerve with subsequent vision loss due to head or craniocerebral trauma. The treatment of this disease is the subject of controversial discussions. The purpose of the present study was to investigate pre- and immediate postoperative visual acuity in patients with unilateral TON and to compare the results with the time interval between trauma and surgical intervention.

PATIENTS AND METHODS

A total of 20 patients with unilateral TON and considerable vision loss were examined. All were treated with high dose corticoids and underwent microsurgical optic nerve decompression. Visual acuity was determined pre- and postoperatively. In long-term follow-up visual acuity was determined 3 months postoperatively.

RESULTS

Postoperatively, nine patients (45%) achieved an improvement in visual acuity of more than 0.4, and another three patients (15%) an improvement of ≥0.2. At 3 months postoperatively another four patients achieved a further improvement of their visual acuity of >0.2. A decrease in visual acuity was not observed in any case, nor were major surgical complications.

CONCLUSIONS

Factors which predict good prognosis for vision recovery include a short time interval between trauma and intervention, edema, and/or hematoma of the optic nerve sheath. Factors which predict a worse prognosis are a fracture line directly through the nerve canal, a time period between trauma and intervention of more than 24 h, and initial complete amaurosis.

Intraoperative radiotherapy (IORT) with low-energy x-rays for breast cancer

607

Background: IORT for breast cancer using either electrons or low-energy x-rays is of increasing interest over the last few years. In our institution, IORT is delivered by a mobile x-ray source (Intrabeam™) producing isotropic 50 kV x-ray fields. Because this treatment method includes single high doses to the normal breast tissue, careful and long-term evaluation of early and late toxicity is mandatory. To date there are still fewdata on long-term follow-up of patients treated with low-energy x-rays. Methods: Between 2/02 and 12/06 204 breast cancer patients received IORT either as a tumour-bed boost (133) followed by 46 Gy external beam radiotherapy (EBRT) or as partial breast irradiation (PBI) only (71). Median age was 66.4 years (35–95), median tumour size was 9 mm (1–45). Spherical applicators (median 4. 0 cm) were inserted into the tumour-cavity and a single dose of 20 Gy was given. Follow-up (f/u) included physical examination and ultrasound 1 week, 2 months, then every 6 months after therapy and mammography at yearly intervals. Radiobiological modelling of the expected spatial distribution of late reactions was done for typical cases using the linear-quadratic model with special consideration of relative biological effectiveness, spatial dose distribution and dose rate. Results: Median f/u was 28 months (1–56). Minor postoperative side effects included erythema (5%), delayed wound healing (4%), mastitis (1%) and hematoseroma (4%). A fibrotic induration of the tumour bed was observed in 9, 18, 24, 23, 26% and 24% of the patients at 2, 6 12, 24, 36 and 48 month f/u. These fibrosis rates were distributed equally in both groups. Reoperation was required in 2 patients after 10 (fibrosis) and 12 months (fat necrosis). Conclusions: Although two thirds of the patients were treated with a combination of IORT and EBRT, acute reactions in all patients were mild. A fibrotic induration confined to the tumourbed was observed in up to 25% of all patients after 2 years. The low level of clinically observed late reactions so far is in agreement with predictions from radiobiological modelling.

No significant financial relationships to disclose.

Classification of patients with a clinically isolated syndrome based on signs and symptoms is supported by magnetic resonance imaging results

BACKGROUND

Recently, a clinical classification system was described to determine whether symptoms and signs of patients presenting with a first episode suggestive of multiple sclerosis (MS) indicate the presence of monofocal or multifocal disease.

OBJECTIVES

To evaluate the value of this new classification system by comparing the results with those of simultaneously obtained magnetic resonance imaging (MRI) scans.

METHODS

The 487 patients, randomised in the BENEFIT study, were centrally assessed using the new system and classified as monofocal or multifocal, based on clinical information by two neurologists masked for the MRI results. MRI analyses were performed by expert readers masked for the clinical classification.

RESULTS

Patients classified as multifocal had more T2 hyperintense (median: 21 versus 15.5) and more T1 hypo-intense lesions (median: 2 versus 1) than those classified as monofocal. Patients classified at the local site as having evidence of a single clinical lesion, but reclassified centrally as having a clinical multifocal central nervous system presentation, had more T2 lesions than monofocal patients. In addition, patients with a multifocal presentation more often fulfilled the MRI criteria for dissemination in space, as incorporated in the International Panel (IP) diagnostic criteria for MS.

CONCLUSION

These data provide justification for the recently proposed clinical classification system to be used in patients who present with a first episode suggestive of MS, in that ;multifocal', based on symptoms and signs, is associated with more lesions on MRI.

Early mammographic and sonographic findings after intraoperative radiotherapy (IORT) as a boost in patients with breast cancer

The aim of this study was to evaluate mammographic and sonographic changes at the surgical site within the first 2 years after IORT as a boost followed by whole-breast radiotherapy (WBRT), compared with a control group treated with WBRT alone. All patients had breast-conserving surgery for early-stage breast cancer. Group A: n = 27, IORT (20 Gy) followed by WBRT (46 Gy). Group B (control group): n = 27, WBRT alone (56-66 Gy). Mammography: fat necrosis in 14 group A versus four group B patients (P < 0.001); parenchymal scarring classified as unorganized at the last follow-up in 16 vs seven cases, respectively (P = 0.03). Ultrasound: overall number of patients with circumscribed findings 27 vs 18 (P < 0.001); particular hematomas/seromas in 26 vs 13 patients (P < 0.001). Synopsis of mammography and ultrasound: overall postoperative changes were significantly higher classified in group A (P = 0.01), but not judged to have a significantly higher impact on interpretation. Additional diagnostic procedures, due to unclear findings at the surgical site, were performed on four patients of both groups. Within the first 2 years after IORT as a boost, therapy-induced changes at the original tumor site are significantly more pronounced compared with a control group. There is no evidence that the interpretation of findings is complicated after IORT.